Sensory impairment after stroke: Exploring therapists' clinical decision making

Clinical Reasoning in Occupational Therapy Practice: A Scoping Review of Qualitative and Conceptual Peer-Reviewed Literature

IMPORTANCE

The occupational therapy clinical reasoning literature includes a large proportion of peer-reviewed qualitative and conceptual articles. Although these articles can contribute to the understanding of how clinical reasoning has been conceptualized in occupational therapy, they have not yet received in-depth analytic attention. To address this gap, we conducted a scoping review.

OBJECTIVE

To examine how qualitative and conceptual literature has addressed clinical reasoning in occupational therapy.

DATA SOURCES

Database searches were conducted in Scopus, Web of Science, PsycINFO, Embase, and MEDLINE.

STUDY SELECTION AND DATA COLLECTION

Included articles were published between 2010 and 2019, were peer reviewed, addressed clinical reasoning in occupational therapy, were qualitative or conceptual articles, focused on practitioners, and were in English. Twenty-six articles met the inclusion criteria. Data were extracted according to relevant categories and were analyzed numerically and thematically.

FINDINGS

Four themes were identified: clinical reasoning processes, factors influencing clinical reasoning, new models or frameworks to guide clinical reasoning, and emergent perspectives on clinical reasoning.

CONCLUSIONS AND RELEVANCE

This review advances knowledge about how clinical reasoning has been conceptualized in occupational therapy and has been applied in a range of practice contexts. The review highlights discussions about types of reasoning, the dynamic and iterative nature of reasoning, contextual dimensions of reasoning, client-centered and occupation-based approaches, new frameworks and models, and emergent and innovative perspectives on clinical reasoning in occupational therapy. What This Article Adds: This scoping review represents an important contribution to knowledge about how clinical reasoning has been conceptualized in occupational therapy by mapping key themes and illuminating scholarly conversations in the qualitative and conceptual clinical reasoning literature.

Experiences of SENSory Relearning of the UPPer Limb (SENSUPP) after Stroke and Perceived Effects: A Qualitative Study

Recently, it was shown that sensory relearning of the upper limb (SENSUPP) is a promising intervention to improve sensorimotor function after stroke. There is limited knowledge, however, of how participants perceive the training. Here, we explored how persons with sensory impairments in the upper limb experienced the SENSUPP protocol (combined sensory- and motor training and home exercises for 5 weeks) and its effect. Fifteen persons (mean age 59 years; 10 men; >6 months post-stroke) were individually interviewed, and data were analyzed with qualitative content analysis. An overall theme ‘Sensory relearning was meaningful and led to improved ability to perform daily hand activities’ and two categories with six subcategories emerged. The outpatient training was perceived as meaningful, although the exercises were demanding and required concentration. Support from the therapist was helpful and training in small groups appreciated. The home training was challenging due to lack of support, time, and motivation. Small improvements in sensory function were perceived, whereas increased movement control and ability in performing daily hand activities were reported. In conclusion, the SENSUPP protocol is meaningful and beneficial in improving the functioning of the UL in chronic stroke. Improving compliance to the home training, regular follow-ups, and an exercise diary are recommended.

Somesthetic, Visual, and Auditory Feedback and Their Interactions Applied to Upper Limb Neurorehabilitation Technology: A Narrative Review to Facilitate Contextualization of Knowledge

Reduced hand dexterity is a common component of sensorimotor impairments for individuals after stroke. To improve hand function, innovative rehabilitation interventions are constantly developed and tested. In this context, technology-based interventions for hand rehabilitation have been emerging rapidly. This paper offers an overview of basic knowledge on post lesion plasticity and sensorimotor integration processes in the context of augmented feedback and new rehabilitation technologies, in particular virtual reality and soft robotic gloves. We also discuss some factors to consider related to the incorporation of augmented feedback in the development of technology-based interventions in rehabilitation. This includes factors related to feedback delivery parameter design, task complexity and heterogeneity of sensory deficits in individuals affected by a stroke. In spite of the current limitations in our understanding of the mechanisms involved when using new rehabilitation technologies, the multimodal augmented feedback approach appears promising and may provide meaningful ways to optimize recovery after stroke. Moving forward, we argue that comparative studies allowing stratification of the augmented feedback delivery parameters based upon different biomarkers, lesion characteristics or impairments should be advocated (e.g., injured hemisphere, lesion location, lesion volume, sensorimotor impairments). Ultimately, we envision that treatment design should combine augmented feedback of multiple modalities, carefully adapted to the specific condition of the individuals affected by a stroke and that evolves along with recovery. This would better align with the new trend in stroke rehabilitation which challenges the popular idea of the existence of an ultimate good-for-all intervention.

SENSory re-learning of the UPPer limb (SENSUPP) after stroke: development and description of a novel intervention using the TIDieR checklist

Background

Sensorimotor impairments of upper limb (UL) are common after stroke, leading to difficulty to use the UL in daily life. Even though many have sensory impairments in the UL, specific sensory training is often lacking in stroke rehabilitation. Thus, the aim of this paper is to provide a detailed description of the novel intervention “SENSory re-learning of the UPPer limb after stroke (SENSUPP)” that we have developed to improve functioning in the UL in persons with mild to moderate impairments after stroke.

Methods

The SENSUPP protocol was designed using information from literature reviews, clinical experience and through consultation of experts in the field. The protocol integrates learning principles based on current neurobiological knowledge and includes repetitive intensive practice, difficulty graded exercises, attentive exploration of a stimulus with focus on the sensory component, and task-specific training in meaningful activities that includes feedback. For reporting the SENSUPP protocol, the Template for Intervention Description and Replication (TIDieR) checklist was used.

Results

The essential features of the SENSUPP intervention comprise four components: applying learning principles based on current neurobiological knowledge, sensory re-learning (exercises for touch discrimination, proprioception and tactile object recognition), task-specific training in meaningful activities, and home-training. The training is performed twice a week, in 2.5-h sessions for 5 weeks.

Conclusion

Since there is close interaction between the sensory and motor systems, the SENSUPP intervention may be a promising method to improve UL functioning after stroke. The TIDieR checklist has been very useful for reporting the procedure and development of the training.

Trial registration

ClinicalTrials.govNCT03336749. Registered on 8 November 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05375-6.

Factors influencing allied health professionals' implementation of upper limb sensory rehabilitation for stroke survivors: a qualitative study to inform knowledge translation

OBJECTIVES

Somatosensory loss is common after stroke with one-in-two individuals affected. Although clinical practice guidelines recommend providing somatosensory rehabilitation, this impairment often remains unassessed and untreated. To address the gap between guideline recommendations and clinical practice, this study sought to understand the factors influencing delivery of evidence-based upper limb sensory rehabilitation after stroke.

DESIGN

Qualitative study involving focus groups and interviews. Data analysis used an inductive approach (thematic analysis) and deductive analysis using implementation theory (the Theoretical Domains Framework and Normalisation Process Theory).

SETTING

Eight healthcare organisations in metropolitan and regional areas of Victoria and New South Wales, Australia.

PARTICIPANTS

Eighty-seven rehabilitation therapists (79% occupational therapists and 21% physiotherapists) were purposively sampled and participated in a knowledge translation study with staggered recruitment from 2014 to 2018.

RESULTS

Three types of factors influenced therapists' delivery of upper limb somatosensory rehabilitation: individual ('The uncertain, unskilled therapist'), patient ('Patient understanding and priorities') and organisational ('System pressures and resources'). Deductive analysis using implementation theory identified key determinants of practice change, such as opportunities to consolidate new skills, the anticipated benefits of upskilling as a therapy team and the work anticipated by therapists to incorporate a new somatosensory rehabilitation approach.

CONCLUSIONS

Occupational therapists and physiotherapists hold valuable insights towards practice change in somatosensory rehabilitation from the 'frontline'. Therapists experience barriers to change including a lack of knowledge and skills, lack of resources and organisational pressures. Facilitators for change were identified, including social support and therapists' perceived legitimacy in using new somatosensory rehabilitation approaches. Results will inform the design of a tailored implementation strategy to increase the use of evidence-based somatosensory rehabilitation in Australia.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12615000933550).

Learning and Development of Diagnostic Reasoning in Occupational Therapy Undergraduate Students

Background/Aim

One way to facilitate occupational therapy undergraduate students transferring their academic skills of data gathering and analysis to professional settings is to ensure they can competently use diagnostic reasoning. Nevertheless, there are several obvious gaps in empirical evidence related to the learning and development of this style of reasoning in occupational therapy undergraduates. The most important are related to promoting higher-order thinking and the use of information to solve problems in the context of professional practice. This study analyses undergraduates' diagnostic reasoning and its changes during their education.

Materials and Methods

This multicentre study was conducted with a descriptive observational design. The study took place at the University of Coruña (Spain), University of Castilla-La Mancha (Spain), and University of el Valle (Colombia). The sample was n = 247. For data collection, a clinical case was specifically designed. IBM SPSS Statistics (v19) and EPIDAT 3.1 were used for the data analysis.

Results

Participants identified and categorized occupational performance problems. However, they had difficulties when identifying and categorizing the occupational performance components (specifically, the symptoms and signs of the disease presented in the study case). They presented limitations to analyse and synthesize the information collected to develop an explanation of the occupational problems and their causes.

Conclusions

Undergraduate students' ability to analyse and synthesize information during data collection is poorly organized, so it makes the problem formulation difficult. This study contributes to the knowledge of undergraduates' diagnostic reasoning features, specifically the undergraduate students' capacities and limits to process information during the occupational assessment.

The effectiveness of somatosensory retraining for improving sensory function in the arm following stroke: a systematic review

OBJECTIVE

The aim of this study was to evaluate if somatosensory retraining programmes assist people to improve somatosensory discrimination skills and arm functioning after stroke.

DATA SOURCES

Nine databases were systematically searched: Medline, Cumulative Index to Nursing and Allied Health Literature, PsychInfo, Embase, Amed, Web of Science, Physiotherapy Evidence Database, OT seeker, and Cochrane Library.

REVIEW METHODS

Studies were included for review if they involved (1) adult participants who had somatosensory impairment in the arm after stroke, (2) a programme targeted at retraining somatosensation, (3) a primary measure of somatosensory discrimination skills in the arm, and (4) an intervention study design (e.g. randomized or non-randomized control designs).

RESULTS

A total of 6779 articles were screened. Five group trials and five single case experimental designs were included ( N = 199 stroke survivors). Six studies focused exclusively on retraining somatosensation and four studies focused on somatosensation and motor retraining. Standardized somatosensory measures were typically used for tactile, proprioception, and haptic object recognition modalities. Sensory intervention effect sizes ranged from 0.3 to 2.2, with an average effect size of 0.85 across somatosensory modalities. A majority of effect sizes for proprioception and tactile somatosensory domains were greater than 0.5, and all but one of the intervention effect sizes were larger than the control effect sizes, at least as point estimates. Six studies measured motor and/or functional arm outcomes ( n = 89 participants), with narrative analysis suggesting a trend towards improvement in arm use after somatosensory retraining.

CONCLUSION

Somatosensory retraining may assist people to regain somatosensory discrimination skills in the arm after stroke.

What influences decisions about ongoing stroke rehabilitation for patients with pre-existing dementia or cognitive impairment: a qualitative study?

OBJECTIVE

To identify factors influencing clinicians decision-making about ongoing stroke rehabilitation for people with pre-existing dementia/cognitive impairment and the impact on clinical practice.

DESIGN

Qualitative semi-structured interviews with stroke specialist healthcare professionals analysed using thematic analysis.

SETTING

Acute stroke unit, inpatient stroke rehabilitation units, and community stroke services.

PARTICIPANTS

Twenty three professionals from six multidisciplinary stroke teams involved in decision-making about stroke patients' rehabilitation potential and clinical pathways.

RESULTS

Factors influencing decision-making about ongoing rehabilitation were (1) gaining understanding of the individual patient, (2) clinician's knowledge of dementia/cognitive impairment, (3) predicting rehabilitation potential, (4) organizational constraints, and (5) clinician's perceptions of their role within the team. Decision-making led to two outcomes, either accommodating the pre-existing dementia/cognitive impairment within delivery of rehabilitation or ending rehabilitation for that patient to allocate limited resources where they were perceived more likely to be effective. Participants felt that patients with pre-existing dementia/cognitive impairment had difficulty demonstrating the required rehabilitation potential within the short timescales available in the current model of service delivery. Participants identified a need for training to improve their knowledge and confidence for decision-making and delivery of rehabilitation for this growing population.

CONCLUSION

Clinicians' decision-making about ongoing rehabilitation for patients with prestroke dementia/cognitive impairments is influenced by gaps in their knowledge and by service constraints. Increased training and more flexible, patient-centred services would enable clinicians to better accommodate these patients in rehabilitation.